ABSTRACT
Mr. J is a 34-year-old White male who presented to his primary care provider with bilateral lower extremity muscle cramping, nausea, and fatigue with usual activities for 2 weeks; the remainder of his review of systems was acutely negative. He reported taking no current medications and has no known medical allergies. He denied tobacco and drug use but admitted to drinking an occasional glass of wine. In addition, 4 years ago, he was diagnosed with testicular cancer (seminoma) and had undergone a left orchiectomy and subsequent focused abdominal/pelvic irradiation for 4 weeks. He reported his brother (3 years older) had also been diagnosed with testicular cancer (teratoma) and had undergone a left orchiectomy with a retroperitoneal lymphadenectomy. He reported no other significant family history. Mr. J's subsequent tumor-specific markers-alpha-fetoprotein (AFP)-remained normal.One year postorchiectomy and irradiation, he developed a left renal calculus, which required an ED visit for diagnosis and pain management, and later consultation with a nephrologist. He then had a subsequent successful lithotripsy. Serum calcium levels at the time of the renal calculus diagnosis were reported as 13 mg/dL; urine analysis revealed calcium oxalate crystals, and no further workup was initiated. He was directed to decrease his intake of dietary calcium and to continue his annual follow-up visits for tumor markers. He reported no further episodes associated with renal stones.On this visit, his vital signs and body weight were within normal range. On physical exam, he appeared fatigued, but his neurologic, neck, chest, abdominal, lymph node, and extremity exams were unremarkable. Due to the current symptomatology and his past history of renal calculus and testicular cancer, a comprehensive lab workup was ordered and included complete blood count, coagulation studies (protime, partial thromboplastin time), a complete metabolic panel (CMP), serum tumor markers (AFP), a thyroid panel, and

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